Published online in the journal Pain Medicine, the study is the first to examine factors associated with opioid dose escalation during the first year of use and may help physicians identify patients who should not continue taking medications such as hydrocodone, codeine or oxycodone.
“Most physicians recognize that they need to carefully monitor patients who are prescribed high doses of opioid pain medication, but patients nearly always start these medications at lower doses and increase to more dangerous levels over time,” said Stephen Henry, assistant professor of general medicine and lead author of the study. “We wanted to develop a more complete picture of the patients who should raise red flags early in the course of pain therapy, before their dose levels put them at high risk of overdose or death.”
Henry and his colleagues evaluated the medical records of nearly 250 adult patients given opioid painkillers for musculoskeletal pain between July 2011 and June 2012, but not during the prior year. They then compared those whose doses escalated with those whose doses remained stable in terms of diagnoses, medications, number and type of health-care encounters, and demographics such as age, race and gender.
Two significant differences emerged: Patients whose doses escalated were more likely to have been previously diagnosed with a substance-use disorder (17 percent versus 1 percent) or they had more frequent communication with their doctors’ offices (an average of 16 additional encounters). Many of those additional encounters were via telephone or email, rather than in person.
Henry hopes the study results can help primary care physicians, who write the vast majority of pain medicine prescriptions, identify patients whose opioid use needs to be re-evaluated and whose pain may be better treated with non-opioid medications.
According to the U.S. Centers for Disease Control and Prevention, drug overdose is the leading cause of injury death in the U.S. and overdose from prescription medications exceeds deaths from heroin and cocaine combined. Of the 22,114 deaths relating to pharmaceutical overdose in 2012, 72 percent involved opioid painkillers. For additional information, visit the CDC website.
“Conversations with patients about pain medicine can be uncomfortable, in part because physicians have a hard time predicting who is likely to be a problem user and who isn’t,” said Henry, whose research focuses on addressing pain in primary care settings. “We hope our study can help minimize the number of patients who progress to high medication doses and eventually help reduce the number of patients harmed by these medications.”
Henry’s co-authors on the study were Barth Wilsey, Joy Melnikow and Ana-Maria Iosif of UC Davis. Wilsey is also a physician with the VA Northern California Health Care System.
The study, “Dose Escalation During the First Year of Long-Term Opioid Therapy for Chronic Pain,” was funded by the UC Davis Center for Healthcare Policy and Research and National Center for Advancing Translational Sciences (grants UL1 TR000002 and KL2 TR000134). It is available online at http://onlinelibrary.wiley.com/doi/10.1111/pme.12634/pdf
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